Patient factors related to patient engagement technology (PET) usage in thoracic surgery.

BACKGROUND: We evaluated using Patient Engagement Technology (PET) to capture Patient Reported Outcomes (PROs) in thoracic surgery patients. METHODSY: atients using a PET received surveys including the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) and a health literacy (HL) screen. The relationship of patient-level factors with survey completion was assessed through univariate and logistic regression analyses. RESULTS: 703 patients enrolled in a PET. 52 â€‹% were female and 83 â€‹% were white with a median age of 63.72 â€‹% had adequate HL. 81 â€‹% completed the PROMIS-10 survey. Univariate analysis found lower rates of PROMIS-10 completion in male patients and those with inadequate HL. Logistic regression analysis showed adequate HL (OR 1.76) and white race (OR 1.72) were associated with PROMIS-10 survey completion, while male gender (OR 0.65) had the opposite effect. CONCLUSIONS: PETs are an effective means of collecting PROs, but use is affected by gender, race, and health literacy.

Sublobar Resections: Indications and Approaches.

Sublobar resections are commonly performed operations that have seen an increase in applicability. The sublobar approach, comprising segmentectomy and wedge resections, can provide lung preservation and thus is better tolerated in select patients in comparison to lobectomy. These operations are offered for a variety of benign and malignant lesions. Understanding the indications and technical aspects of these approaches is paramount as improvements in lung cancer screening protocols and the imaging modalities has led to an increase in the detection of early-stage cancer. In this article, we discuss the anatomy, indications, technical approaches, and outcomes for sublobar resection.

Resection Versus Observation for Small (≤2 cm) Pancreatic Neuroendocrine Tumors.

BACKGROUND: We hypothesized that those patients with pancreatic neuroendocrine tumors (pNETs) ≤2 cm managed nonoperatively would have comparable disease progression to individuals undergoing an operation. METHODS: Patients diagnosed with nonfunctional pNETs ≤ 2 cm who were evaluated at a single comprehensive cancer center from 2010 to 2017 were selected from a cancer registry database. Clinicopathologic variables were obtained via retrospective chart review. Primary outcomes were overall and disease specific survival. Variables were compared between the 2 groups using chi-square and independent t-test. RESULTS: Fifty-two individuals had tumors ≤2 cm, of whom 75% had an operation, while 25% were observed. Each treatment arm had similar distributions of gender, race, and tumor location. The most common operation was distal pancreatectomy (n = 29) followed by pancreatoduodenectomy (n = 6). Nine patients had grade III postoperative complications and 4 had grade IV under Clavien-Dindo classification. The observation group was noted to have a mean disease progression interval of 80.9 months, while those who underwent an operation had a mean disease progression interval of 94.6 months (P = .246). CONCLUSIONS: Overall disease progression in patients with pNETs ≤ 2 cm without evidence of metastasis at the time of presentation is not different between those who underwent operation compared to those observed.

Evolution of technique and results after permanent open repair for pectus deformities.

Objective: Open correction of pectus deformities has evolved since its origin. We performed a Ravitch type repair using a permanent titanium plate fixed with screws and describe the procedure with outcomes after our modifications. Methods: A retrospective review of 61 pectus excavatum and pectus carinatum cases from August 2013 to April 2021 was performed. Data were extracted from medical records and reported. In January 2016, we began administering satisfaction surveys at the 6-month postoperative visit; results are reported. Results: The mean age of our cohort was 24.5 years; 43 (70%) were male. Fifty-four underwent pectus excavatum repair, 6 pectus carinatum repair, and 1 mixed repair. Median Haller index was 3.8. Mean operative duration was 98 minutes; mean blood loss was 116.4 mL. Median chest tube duration was 5.0 days; median hospital stay was 4 days. Reexploration for bleeding was 30% in the first 10 patients. Protocol changes including postponing chemical deep vein thrombosis prophylaxis, using intraoperative hemostatic agents, and using shorter implantation screws decreased this to 0% for the remaining cases. The most frequent complication was urinary retention (21.3%). Postoperative surveys were completed for 37 of 50 patients. Seventy-five percent reported health improved, 65% reported exercise capacity improved, 75% reported breathing improved, and 59% reported chest pain improved. Self-esteem improved from 6.6 ± 2.5 (of 10) before surgery to 8.2 ± 2.1 after surgery. Ninety percent were satisfied and 86% would have the operation again. Conclusions: Ravitch type repair with permanent titanium plate fixation is a safe and effective procedure for correction of pectus excavatum and carinatum. Most patients experience improvement in preoperative symptoms.

Relationship between burnout and mistreatment: Who plays a role?

INTRODUCTION: Surgery residents have high burnout rates and mistreatment occurs during training. We hypothesized that residents who reported mistreatment would be more likely to experience burnout. METHODS: A multi-institutional observational study asked residents to complete the Maslach Burnout Inventory and to rate how often they experienced mistreatment. Scores in the high-risk range for emotional exhaustion or depersonalization were classified as burnout. Associations between mistreatment behaviors, program, sex, post graduate year(PGY), and clinical status were measured by Spearman's correlation, linear regression, and logistic regression. RESULTS: We invited 398 residents to participate; 180 responded(45%). 52%(n = 93) were female, there was an even distribution among PGY, and seven programs were represented. Almost half of the cohort (48%) reported high risk for burnout and 68% reported experiencing mistreatment. Mistreatment by senior physician team members were correlated with EE(rho = 0.184,p = 0.016) and DP(rho = 0.181,p = 0.016). CONCLUSION: While overall burnout was not significantly associated with mistreatment behaviors, both burnout and mistreatment were commonly reported.

Patient, Nurse, Medical Assistant, and Surgeon Perspectives Inform the Development of a Decision Support Tool for Inguinal Hernia Surgery: A Qualitative Analysis.

BACKGROUND: Critical perspectives on the informed consent process for inguinal hernia surgery are lacking. METHODS: We conducted focus group interviews of patients who have undergone inguinal hernia surgery and nurses/medical assistants. Individual phone interviews were also conducted with surgeons sampled from the International Hernia Collaboration. Interviews were transcribed for coding and qualitative thematic analysis performed using NVivo 12 Plus. Themes were compiled to develop a decision aid. RESULTS: Sixteen patients, 6 support staff members, and 12 surgeons participated. Multiple themes were identified. Patients, nurses, and medical assistants identified barriers to asking questions in the current clinic setup, patient stress, and time constraints, while surgeons identified strategies to implement decision aids. All participants agreed that decision aids improve the informed consent process. CONCLUSION: Key stakeholders identified barriers to the informed consent process and provided input on necessary components of a decision aid. Opportunities exist to address these barriers and improve the consent process.

First Genome of Labyrinthula sp., an Opportunistic Seagrass Pathogen, Reveals Novel Insight into Marine Protist Phylogeny, Ecology and CAZyme Cell-Wall Degradation.

Labyrinthula spp. are saprobic, marine protists that also act as opportunistic pathogens and are the causative agents of seagrass wasting disease (SWD). Despite the threat of local- and large-scale SWD outbreaks, there are currently gaps in our understanding of the drivers of SWD, particularly surrounding Labyrinthula spp. virulence and ecology. Given these uncertainties, we investigated the Labyrinthula genus from a novel genomic perspective by presenting the first draft genome and predicted proteome of a pathogenic isolate Labyrinthula SR_Ha_C, generated from a hybrid assembly of Nanopore and Illumina sequences. Phylogenetic and cross-phyla comparisons revealed insights into the evolutionary history of Stramenopiles. Genome annotation showed evidence of glideosome-type machinery and an apicoplast protein typically found in protist pathogens and parasites. Proteins involved in Labyrinthula SR_Ha_C's actin-myosin mode of transport, as well as carbohydrate degradation were also prevalent. Further, CAZyme functional predictions revealed a repertoire of enzymes involved in breakdown of cell-wall and carbohydrate storage compounds common to seagrasses. The relatively low number of CAZymes annotated from the genome of Labyrinthula SR_Ha_C compared to other Labyrinthulea species may reflect the conservative annotation parameters, a specialized substrate affinity and the scarcity of characterized protist enzymes. Inherently, there is high probability for finding both unique and novel enzymes from Labyrinthula spp. This study provides resources for further exploration of Labyrinthula spp. ecology and evolution, and will hopefully be the catalyst for new hypothesis-driven SWD research revealing more details of molecular interactions between the Labyrinthula genus and its host substrate.

Early Elective Surgery After Colon Cancer Diagnosis has Higher Risk of Readmission and Death.

OBJECTIVE: We hypothesized colon resection within 30 days of diagnosis of cancer would have higher rates of readmission and cancer specific mortality, unless there was demonstrated evidence of preoperative workup. SUMMARY BACKGROUND DATA: Few studies have examined if negative consequences exist with expedited elective surgery after diagnosis of colon cancer. Surgery in a shorter time frame may result in a lack of appropriate preoperative care. METHODS: Retrospective analysis of 25,407 patients in the Surveillance Epidemiology and End Results registry who underwent elective surgical resection for colon cancer from 2010 to 2015. Cohort stratified by age (66-75 vs >75 years). Primary outcomes of interest were 30-day readmission and 5-year colon cancer specific mortality. Relationships between timing of surgery and outcomes were assessed. RESULTS: On unadjusted analysis, surgery before 20 days of diagnosis was associated with higher risk of 30-day readmission and colon cancer specific mortality in both age groups. Among those age 66 to 75 years old, adjusting for patient factors and preoperative workup eliminated the risk of 30-day readmission (risk ratio 1.5-0.9 for 0-10 days, risk ratio 1.3-0.9 for 11-20 days). However, the risk for colon cancer specific mortality, although reduced, persisted (hazard ratio 2.2-1.3 for 0-10 days, hazard ratio 2.0-1.2 for 11-20 days). In the cohort older than 75 years, adjusting for patient level factors and preoperative workup eliminated risk of surgery 20 days postop or sooner. CONCLUSIONS: The risk associated with short time to surgery (within 30 days) may be mitigated if full oncologic workups are provided.

Newly emerging diseases of marine turtles, especially sea turtle egg fusariosis (SEFT), caused by species in the Fusarium solani complex (FSSC).

Sea turtles are presently considered severely endangered species that are historically threatened by many environmental factors. Recently, additional threats to sea turtles from two pathogenic species of fungi in the Fusarium solani species complex (F. falciforme and F. keratoplasticum) have been identified. These species infect marine turtle eggs, causing sea turtle egg fusariosis, and kill their embryos, with recent reports of hatch-failure in seven globally distributed species of endangered sea turtles (Caretta caretta, Chelonia mydas, Dermochelys coriaceae, Eretmochelys imbricata, Lepidochelys olivacea, Lepidochelys kempi and Natator depressus). Mycelia and spores of pathogenic species of Fusarium are produced in disturbed terrestrial soils and are transported to the ocean in coastal run off. We propose that these fungi grow on floating particles of plant tissues (leaves and wood), animal tissues, silt and plastics, which are carried by wind and currents and the turtles themselves to the beaches where the turtles lay their eggs.

Do Internal or External Characteristics More Reliably Predict Burnout in Resident Physicians: A Multi-institutional Study.

INTRODUCTION: Surgical residents have been shown to experience high rates of burnout. Whether this is influenced predominately by intrinsic characteristics, external factors, or is multifactorial has not been well studied. The aim of this study was to explore the relationship between these elements and burnout. We hypothesized that residents with higher emotional intelligence scores, greater resilience and mindfulness, and better work environments would experience lower rates of burnout. METHODS: General surgery residents at 7 sites in the US were invited to complete an electronic survey in 2019 that included the 2-item Maslach Burnout Inventory, Brief Emotional Intelligence Scale, Revised Cognitive and Affective Mindfulness Scale, 2-Item Connor-Davidson Resilience Scale, Utrecht Work Engagement Scale, and Job Resources scale of the Job Demands-Resources Questionnaire. Individual constructs were assessed for association with burnout, using multivariable logistic regression models. Residents' scores were evaluated in aggregate, in groups according to demographic characteristics, and by site. RESULTS: Of 284 residents, 164 completed the survey (response rate 58%). A total of 71% of respondents were at high risk for burnout, with sites ranging from 57% to 85% (p = 0.49). Burnout rates demonstrated no significant difference across gender, PGY level, and respondent age. On bivariate model, no demographic variables were found to be associated with burnout, but the internal characteristics of emotional intelligence, resilience and mindfulness, and the external characteristics of work engagement and job resources were each found to be protective against burnout (p < 0.001 for all). However, multivariable models examining internal and external characteristics found that no internal characteristics were associated with burnout, while job resources (coeff. -1.0, p-value <0.001) and work engagement (coeff. -0.76, p-value 0.032) were significantly protective factors. Rates of engagement overall were high, particularly with respect to work "dedication." CONCLUSIONS: A majority of residents at multiple institutions were at high risk for burnout during the study period. Improved work engagement and job resources were found to be more strongly associated with decreased burnout rates when compared to internal characteristics. Although surgical residents appear to already be highly engaged in their work, programs should continue to explore ways to increase job resources, and further research should be aimed at elucidating the mediating effect of internal characteristics on these external factors.

Emotional Intelligence and Burnout in Surgical Residents: A 5-Year Study.

OBJECTIVE: We sought to characterize the interactions of burnout with internal and external factors over the past 5 years for surgery residents at our institution. We hypothesized that burnout levels would be consistent among years, inversely related to emotional intelligence (EI) and job resources, and directly related to disruptive behaviors. DESIGN: General surgery residents at a single institution were invited to complete a survey each year from 2015 to 2019 that included a combination of the 22-item Maslach-Burnout Inventory, 30-item trait EI questionnaire, as well as focused questions assessing disruptive behaviors (8 items), job resources (8 items), and demographic characteristics. Burnout was defined as scoring high in depersonalization (≥ 10 points) or emotional exhaustion (≥ 27 points). Student's t tests and Wilcoxon tests were used to compare continuous variables; chi-square and Fisher's exact tests were used to compare categorical variables, as appropriate. Spearman's rho was used to calculate correlation. A logistic regression and separate linear regression model were constructed to assess relation of variables to burnout. SETTING: The general surgery residency program at the University of Alabama at Birmingham, Birmingham, Alabama, a large tertiary care academic center. RESULTS: An average of 47 surveys were completed each year, for a total of 236 (response rate 81%). One hundred seventeen (58.5%) met criteria for burnout. Burnout rates each year ranged from 68% to 53%, with the lowest value occurring in 2019. Incidence of burnout was lowest among the postgraduate year (PGY) 1 class and highest among the PGY5 class (38% versus 64%, p = 0.02). Individuals without burnout had higher scores for EI overall (5.7 versus 5.3, p < 0.001) as well as in each of its 4 subcomponents (p < 0.001). Individuals who were subjected to disruptive behaviors, particularly others taking credit for work and public humiliation, were more likely to experience burnout (p = 0.02). Those with burnout also had significantly lower scores in each of the 4 domains of the Job Resources model (p < 0.01). On multivariate logistic regression, increasing PGY level remained a significant predictor of burnout risk. Each of the sub-domains of EI and jobs resources inversely corelated with burnout, while disruptive behaviors directly correlated with burnout. ON subsequent multivariable linear regression, resident well-being and professional development remained independent predictors of lower burnout scores. CONCLUSIONS: Burnout is prevalent among trainees at our institution, but a trend toward improvement has been shown over 5 years. Burnout rates increase each year of surgical training beyond PGY2. Factors that mitigate burnout include resident well-being and professional development. Disruptive behaviors lead to increase burnout rates.

The Job Demands-Resources Model as a Framework to Identify Factors Associated With Burnout in Surgical Residents.

BACKGROUND: Surgical residents are a population at high risk for burnout. We hypothesized that surgical residents' burnout would be inversely related to emotional intelligence (EI) and job resources and directly related to experiences of disruptive behavior. MATERIALS AND METHODS: All general surgery residents at a single institution were invited to complete a survey in 2018 that included the Maslach Burnout Inventory, Trait EI Questionnaire Short Form, focused questions assessing disruptive behaviors, job resources, and demographic characteristics. Burnout was defined as scoring high in depersonalization (≥10 points) or emotional exhaustion (≥27 points). Student's t-tests and Wilcoxon tests were used to compare continuous variables; chi-square and Fisher's exact tests were used to compare categorical variables. RESULTS: The survey response rate was 87%. The median respondent age was 30, 51.7% were female, and 48.3% were single. Thirty-five met criteria for burnout (58%). Residents with burnout had lower scores for job resources than residents without burnout (19 versus 26, P < 0.01). Job resources subdomain scores for meaningful feedback and professional development had an inverse association with burnout (P < 0.01 for both). Having experienced any disruptive behavior was associated with burnout (68% versus 32%, P = 0.01). Mean EI scores were also lower for those with burnout (5.18 versus 5.64, P < 0.01). Among EI subcategories, burnout was associated with lower well-being and emotionality (P < 0.01 and P = 0.02, respectively). CONCLUSIONS: Burnout is prevalent among surgery residents, including those at our institution. Experiencing disruptive behaviors and lower perceptions of job resources were associated with higher burnout scores, along with lower scores in EI, and may inform future efforts toward interventions.

Enzymes of early-diverging, zoosporic fungi.

The secretome, the complement of extracellular proteins, is a reflection of the interaction of an organism with its host or substrate, thus a determining factor for the organism's fitness and competitiveness. Hence, the secretome impacts speciation and organismal evolution. The zoosporic Chytridiomycota, Blastocladiomycota, Neocallimastigomycota, and Cryptomycota represent the earliest diverging lineages of the Fungal Kingdom. The review describes the enzyme compositions of these zoosporic fungi, underscoring the enzymes involved in biomass degradation. The review connects the lifestyle and substrate affinities of the zoosporic fungi to the secretome composition by examining both classical phenotypic investigations and molecular/genomic-based studies. The carbohydrate-active enzyme profiles of 19 genome-sequenced species are summarized. Emphasis is given to recent advances in understanding the functional role of rumen fungi, the basis for the devastating chytridiomycosis, and the structure of fungal cellulosome. The approach taken by the review enables comparison of the secretome enzyme composition of anaerobic versus aerobic early-diverging fungi and comparison of enzyme portfolio of specialized parasites, pathogens, and saprotrophs. Early-diverging fungi digest most major types of biopolymers: cellulose, hemicellulose, pectin, chitin, and keratin. It is thus to be expected that early-diverging fungi in its entirety represents a rich and diverse pool of secreted, metabolic enzymes. The review presents the methods used for enzyme discovery, the diversity of enzymes found, the status and outlook for recombinant production, and the potential for applications. Comparative studies on the composition of secretome enzymes of early-diverging fungi would contribute to unraveling the basal lineages of fungi.

Impact of initial temporary abdominal closure in damage control surgery: a retrospective analysis.

Background: Damage control surgery has revolutionized trauma surgery. Use of damage control surgery allows for resuscitation and reversal of coagulopathy at the risk of loss of abdominal domain and intra-abdominal complications. Temporary abdominal closure is possible with multiple techniques, the choice of which may affect ability to achieve primary fascial closure and further complication. Methods: A retrospective analysis of all trauma patients requiring damage control laparotomy upon admission to an ACS-verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was ability to achieve primary fascial closure during initial hospitalization. Results: Two hundred and thirty-nine patients met criteria for inclusion. Primary skin closure (57.7%), ABThera™ VAC system (ABT) (15.1%), Bogota bag (BB) (25.1%), or a modified Barker's vacuum-packing (BVP) (2.1%) were used in the initial laparotomy. Patients receiving skin-only closure had significantly higher rates of primary fascial closure and lower hospital mortality, but also significantly lower mean lactate, base deficit, and requirement for massive transfusion. Between ABT or BB, use of ABT was associated with increased rates of fascial closure. Multivariate regression revealed primary skin closure to be significantly associated with primary fascial closure while BB was associated with failure to achieve fascial closure. Conclusions: Primary skin closure is a viable option in the initial management of the open abdomen, although these patients demonstrated less injury burden in our study. Use of vacuum-assisted dressings continues to be the preferred method for temporary abdominal closure in damage control surgery for trauma.

Cryopreservation methods are effective for long-term storage of Labyrinthula cultures.

Marine heterotrophic protists of the Labyrinthulomycota are of interest for their biotechnological (e.g. thraustochytrid production of lipids) and ecological (e.g. wasting disease and rapid blight by pathogens of the genus Labyrinthula) applications; culture-based laboratory studies are a central technique of this research. However, maintaining such microorganism cultures can be labour- and cost-intensive, with a high risk of culture contamination and die-off over time. Deep-freeze storage, or cryopreservation, can be used to maintain culture back-ups, as well as to preserve the genetic and phenotypic properties of the microorganisms; however, this method has not been tested for the ubiquitous marine protists Labyrinthula spp. In this study, we trialled 12 cryopreservation protocols on 3 Labyrinthula sp. isolates of varying colony morphological traits. After 6 mo at -80°C storage, the DMSO and glycerol protocols were the most effective cryoprotectants compared to methanol (up to 90% success vs. 50% success, respectively). The addition of 30% horse serum to the cryoprotectant solution increased Labyrinthula sp. growth success by 20-30%. We expect that these protocols will provide extra security for culture-based studies, as well as opportunities for long-term research on key Labyrinthula sp. isolates.

Pathogenic Labyrinthula associated with Australian seagrasses: Considerations for seagrass wasting disease in the southern hemisphere.

Marine disease ecology is a growing field of research, particularly for host organisms negatively impacted by a changing climate and anthropogenic activities. A decrease in health and increase in susceptibility to disease has been hypothesised as the mechanism behind wide-spread seagrass die-offs related to wasting disease in the past. However, seagrass wasting disease and the causative pathogen, Labyrinthula, have been vastly understudied in the southern hemisphere. Our aim was to build on the current knowledge of Australian Labyrinthula descriptions and phylogeny, while also providing a first look at wasting disease ecology in Australia. Five seagrass species along a 750km stretch of coastline in southeastern Australia were sampled. The resulting 38 Labyrinthula isolates represented a diversity of morphotypes and five haplotypes of varying phylogenetic clade positions and virulence. The haplotypes clustered with previously-described phylogenetic clades containing isolates from Asia, USA and Europe. Pathogenicity tests confirmed, for the first time, the presence of at least two pathogenic haplotypes in Australia. While historically there have been no reports of wasting disease-related seagrass habitat loss, the presence of pathogenic Labyrinthula highlights the need for disease monitoring and research to understand seagrass wasting disease ecology in Australia.

Key Ecological Roles for Zoosporic True Fungi in Aquatic Habitats.

The diversity and abundance of zoosporic true fungi have been analyzed recently using fungal sequence libraries and advances in molecular methods, such as high-throughput sequencing. This review focuses on four evolutionary primitive true fungal phyla: the Aphelidea, Chytridiomycota, Neocallimastigomycota, and Rosellida (Cryptomycota), most species of which are not polycentric or mycelial (filamentous), rather they tend to be primarily monocentric (unicellular). Zoosporic fungi appear to be both abundant and diverse in many aquatic habitats around the world, with abundance often exceeding other fungal phyla in these habitats, and numerous novel genetic sequences identified. Zoosporic fungi are able to survive extreme conditions, such as high and extremely low pH; however, more work remains to be done. They appear to have important ecological roles as saprobes in decomposition of particulate organic substrates, pollen, plant litter, and dead animals; as parasites of zooplankton and algae; as parasites of vertebrate animals (such as frogs); and as symbionts in the digestive tracts of mammals. Some chytrids cause economically important diseases of plants and animals. They regulate sizes of phytoplankton populations. Further metagenomics surveys of aquatic ecosystems are expected to enlarge our knowledge of the diversity of true zoosporic fungi. Coupled with studies on their functional ecology, we are moving closer to unraveling the role of zoosporic fungi in carbon cycling and the impact of climate change on zoosporic fungal populations.

The First Isolation and Characterisation of the Protist Labyrinthula sp. in Southeastern Australia.

As a result of anthropogenic influences and global climate change, emerging infectious marine diseases are thought to be increasingly more common and more severe than in the past. The aim of our investigation was to confirm the presence of Labyrinthula, the aetiological agent of the seagrass wasting disease, in Southeastern Australia and provide the first isolation and characterisation of this protist, in Australia. Colonies and individual cells were positively identified as Labyrinthula using published descriptions, diagrams, and photographs. Their identity was then confirmed using DNA barcoding of a region of the 18S rRNA gene. Species level identification of isolates was not possible as the taxonomy of the Labyrinthula is still poorly resolved. Still, a diversity of Labyrinthula was isolated from small sections of the southeast coast of Australia. The isolates were grouped into three haplotypes that are biogeographically restricted. These haplotypes are closely related to previously identified saprotrophic clades. The study highlights the need for further investigation into the global distribution of Labyrinthula, including phylogenetic pathogenicity and analysis of host-parasite interactions in response to stressors. Given the results of our analyses, it is prudent to continue research into disease and epidemic agents to better prepare researchers for potential future outbreaks.